Multivessel disease in patients over 75years old with ST elevated myocardial infarction. Current management strategies and related clinical outcomes in the ESTROFA MI+75 nation-wide registry

BACKGROUND

In elderly patients with ST elevated myocardial infarction (STEMI) and multivessel disease (MVD the outcomes related with different revascularization strategies are not well known.

METHODS

Subgroup-analysis of a nation-wide registry of primary angioplasty in the elderly (ESTROFA MI+75) with 3576 patients over 75years old from 31 centers. Patients with MVD were analyzed to describe treatment approaches and 2years outcomes.

RESULTS

Of 1830 (51%) with MVD, 847 (46%) underwent multivessel revascularization either in acute (51%), staged (44%) or both procedures (5%). Patients with previous myocardial infarction and those receiving drug-eluting stents or IIb-IIIa inhibitors were more prone to be revascularized, whereas older patients, females and those with Killip III-IV, renal failure and higher ejection fraction were less likely. Survival free of cardiac death and infarction at 2years was better for those undergoing multivessel PCI (85.8% vs. 80.4%, p<0.0008), regardless of Killip class. Multivessel PCI was protective of cardiac death and infarction (HR 0.60, 95% CI 0.40-0.89; p=0.011). Complete revascularization made no difference in outcomes among those patients undergoing multivessel PCI. The best prognosis corresponded to those undergoing multivessel PCI in staged procedures (p<0.001). A propensity score matching analysis (514 patients in each group) yielded similar results.

CONCLUSIONS

In elderly patients with STEMI and MVD, multivessel PCI was related with better outcomes especially after staged procedures. Among those undergoing multivessel PCI, anatomically defined completeness of revascularization had not prognostic influence.

SUMMARY

We sought to investigate the revascularization strategies applied and their prognostic implications in patients aged over 75years with ST elevated myocardial infarction showing multivessel disease. Of 1830 patients, 847 (46%) underwent multivessel PCI either in acute (51%), staged (44%) or both procedures (5%). Multivessel PCI was independent predictor of cardiac death and infarction with the best prognosis corresponding to those undergoing staged procedures.

Primary Angioplasty in Patients Older Than 75 Years. Profile of Patients and Procedures, Outcomes, and Predictors of Prognosis in the ESTROFA IM+75 Registry

INTRODUCTION AND OBJECTIVES

The proportion of elderly patients undergoing primary angioplasty is growing. The present study describes the clinical profile, procedural characteristics, outcomes, and predictors of outcome.

METHODS

A 31-center registry of consecutive patients older than 75 years treated with primary angioplasty. Clinical and procedural data were collected, and the patients underwent clinical follow-up.

RESULTS

The study included 3576 patients (39.3% women, 48.5% with renal failure, 11.5% in Killip III or IV, and 29.8% with>6hours of chest pain). Multivessel disease was present in 55.4% and nonculprit lesions were additionally treated in 24.8%. Radial access was used in 56.4%, bivalirudin in 11.8%, thromboaspiration in 55.9%, and drug-eluting stents in 26.6%. The 1-month and 2-year incidences of cardiovascular death were 10.1% and 14.7%, respectively. The 2-year rates of definite or probable thrombosis, repeat revascularization, and BARC bleeding>2 were 3.1%, 2.3%, and 4.2%, respectively. Predictive factors were diabetes mellitus, renal failure, atrial fibrillation, delay to reperfusion>6hours, ejection fraction<45%, Killip class III-IV, radial access, bivalirudin, drug-eluting stents, final TIMI flow of III, and incomplete revascularization at discharge.

CONCLUSIONS

Notable registry findings include frequently delayed presentation and a high prevalence of adverse factors such as renal failure and multivessel disease. Positive procedure-related predictors include shorter delay, use of radial access, bivalirudin, drug-eluting stents, and complete revascularization before discharge.

Age related issues in reperfusion of myocardial infarction

Advances in pharmacological treatment and effective early myocardial revascularization have led to improved clinical outcomes in patients with acute myocardial infarction (AMI). However, it has been suggested that compared to younger subjects, elderly AMI patients are less likely to receive evidence-based treatment. Several reasons have been postulated to explain this trend, including uncertainty regarding the benefits of the commonly used interventions in the older age group as well as increased risk associated with comorbidities. The diagnosis, management, and post-hospitalization care of elderly patients presenting with an acute coronary syndrome (ACS) pose many difficulties at present due, at least in part, to the fact that trial data are scanty as elderly patients have been poorly represented in most clinical trials. Thus it appears that these high-risk individuals are often managed with more conservative strategies, compared to younger patients. This article reviews current evidence regarding management of AMI in the elderly.

[Acute coronary syndrome in women. Gender differences]

BACKGROUND AND OBJECTIVE

Our aims was to investigate possible gender differences in the diagnostic assessment, treatment and prognosis of patients admitted with acute coronary syndrome (ACS).

PATIENTS AND METHODS

Prospective study of a cohort of 396 patients consecutively admitted to the coronary unit in the period of 18 months with the diagnoses of ACS. We divided the sample into two groups based on gender: 294 men and 102 women. We analysed the diagnostic assessment, hospital treatment, coronary revascularization (ICP), appearance of heart failure (HF) and in-hospital and 1-year mortality. We analyzed predictors of mortality in a multivariate model.

RESULTS

Women were older (70.9±11.9 versus 64.4±12.0; P<.001) and had more comorbidities such as hypertension (70.5% versus 53.7%; P=.003), diabetes (51.0% versus 33.3%; P<.01) and HF (20.5% versus 9.1%; P<.01) than men, while men had greater frequency of smoking (54.42% versus 13.73%; P<.001). Women had higher incidence of cardiogenic shock on admission. There were no differences in thrombolysis and women did not have a different pattern of access to coronary angiography, but men had greater frequency of ICP (50.8% versus 34.6%; P<.01). Women were more likely to develop a higher in-hospital HF (32.6% versus 25.9%; P<.05) and in-hospital mortality (17.6% versus 4.7%; P<.001). In the multivariate analyses, HF on admission OR 8.98 (3.29-24.47), older age OR 1.07 (1.01-1.13) and female gender OR 3.14 (1.27-7.74), were independent predictors of in-hospital mortality.

CONCLUSIONS

In our study, female gender was an independent predictor of in-hospital mortality in patients with ACS.

Evolución en los últimos 20 años en el perfil demográfico, epidemiológico y clínico, técnica y resultados de los procedimientos coronarios percutáneos

INTRODUCTION AND OBJECTIVES

The aim of this study was to describe the changes observed in clinical practice in our interventional cardiology unit over the last 20 years.

METHODS

Between January 1, 1986 and December 31, 2005, >or=17,204 percutaneous transluminal coronary angioplasties (PTCAs) were performed at our center. They were analyzed in four periods of 5 years each. After each procedure, prospective data on patient, procedural, and outcome variables were recorded. The data were analyzed with regard to when the procedure was performed, and the patients' sex and age (i.e., < or >or=75 years). Data from 2006 were used as a reference, but were not included in the analysis.

RESULTS

The number of PTCAs increased significantly. Over the time period, mean patient age increased (from 57[10] years to 62[12] years for males and from 66[10] years to 70[11] years for females), and there were significant increases in the proportions of women (from 16% to 22%) and patients aged >75 years (from 7% to 22%). Among men, the incidence of smoking decreased while that of hypertension, diabetes and hyperlipemia increased. Among women, however, there was no change in risk factors. The numbers of urgent and emergent procedures (17% of PTCAs were for acute myocardial infarction in 2006) increased in both sexes and age groups, more ad hoc procedures were carried out, and more lesions were treated, usually with a stent. Over time, the success rate increased and the complication rate decreased in both sexes and age groups. In-hospital mortality for all procedures, except those for acute myocardial infarction, was 0.7% in males and 1.4% in females (P=.012).

CONCLUSIONS

Significant changes were observed over the last 20 years in the baseline characteristics of, the techniques used in, and the outcomes obtained in patients undergoing percutaneous coronary intervention.

Actualización en cardiopatía isquémica 2005

This article is a review of the main developments in acute coronary syndromes reported in publications and conference presentations in 2005. It covers the pathophysiology, secondary prevention, prognosis, and treatment of ST-segment elevation and non-ST-segment elevation acute coronary syndromes, and the latest clinical practice guidelines.